Data and Technical Assistance (DATA) Task Order to Support the Infant Mortality CoIIN

Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Data and Technical Assistance (DATA) Task Order to Support the Infant Mortality CoIIN Form
1 DATA CoIIN_ Post-TA Webinar Evaluation Survey.pdf DATA CoIIN_TA Webinar Evaluation Survey.pdf Form
2 DATA CoIIN_Post-Stakeholder Webinar Evaluation Survey.pd DATA CoIIN_Stakeholder Webinar Evaluation Survey.pdf Form
3 DATA CoIIN_Web-based Shared workspace/Online Platform Su DATA CoIIN_Online Platform Survey.pdf Form
GENERIC - Supporting Statement_DATA CoIIN_030918.docx Generic DATA COIIN Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Data and Technical Assistance (DATA) Task Order to Support the Infant Mortality CoIIN	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	DATA CoIIN_ Post-TA Webinar Evaluation Survey.pdf	DATA CoIIN_TA Webinar Evaluation Survey.pdf	Yes	Yes	Fillable Fileable
Form	2	DATA CoIIN_Post-Stakeholder Webinar Evaluation Survey.pdf	DATA CoIIN_Stakeholder Webinar Evaluation Survey.pdf	Yes	Yes	Fillable Fileable
Form	3	DATA CoIIN_Web-based Shared workspace/Online Platform Survey.pdf	DATA CoIIN_Online Platform Survey.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 540	Number of Respondents for Small Entity: 53

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,670	2,670
Annual IC Time Burden (Hours)	214	214
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Generic DATA COIIN Supporting Statement	GENERIC - Supporting Statement_DATA CoIIN_030918.docx	03/14/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.